Provider survival strategies in an at-risk environment - Alvarez ...

PROVIDER SURVIVAL STRATEGIES IN AN AT-RISK ENVIRONMENT

For all inquiries, please contact: David Gruber, MD, MBA Managing Director and Director of Research +1 212 763 9801 dgruber@

Special thanks to Ossy Onumonu for contributing to this report.

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Consider the impact on American services if other industries routinely operated in the same manner as many aspects of health care:

If banking were like health care, automated teller machine (ATM) transactions would take not seconds but perhaps days or longer as a result of unavailable or misplaced records.

If home building were like health care, carpenters, electricians, and plumbers each would work with different blueprints, with very little coordination.

If shopping were like health care, product prices would not be posted, and the price charged would vary widely within the same store, depending on the source of payment.

If automobile manufacturing were like health care, warranties for cars that require manufacturers to pay for defects would not exist. As a result, few factories would seek to monitor and improve production line performance and product quality.

If airline travel were like health care, each pilot would be free to design his or her own preflight safety check, or not to perform one at all.

Source: National Academies of Sciences. Best Care at Lower Cost: The Path to Continuously Learning Healthcare in America, 2013

PROVIDER SURVIVAL STRATEGIES IN AN AT-RISK ENVIRONMENT 5

TABLE OF CONTENTS

Foreword

1

Executive Summary

2

List of Figures

6

Critical Strategic Imperatives

Patient Care (Delivery) Transformation

8

Population Health Management

22

Payment Reform Risk Management

31

Actionable Insights ("Big Data")

48

Sustainable Physician Behavior Change (Alignment)

60

Sustainable Patient (Caregiver) Behavior Change (Engagement)

72

Suggested Next Steps

82

Endnotes

86

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HEALTH CARE: PROVIDER SURVIVAL STRATEGIES IN AN AT-RISK ENVIRONMENT

Foreword

In this report, Alvarez & Marsal (A&M) provides its perspective on the transformative actions required by providers to succeed in an at-risk, value-based environment. Notwithstanding the election of President Trump, the appointment (and subsequent resignation) of Tom Price, M.D., as secretary of the Department of Health and Human Services, and the recent Centers for Medicare and Medicaid Services (CMS) proposal to eliminate cardiac care and fracture management episode payment (bundle) models and to reduce the number of mandated comprehensive joint replacement (CJR) markets from 67 to 34, A&M believes that payment reform is inevitable. The rate of change remains difficult to forecast, and will vary by market.

According to CMS, national healthcare expenditures will increase from $3.5 trillion in 2017 to $5.5 trillion in 2025 -- two trillion dollars in only eight short years -- and account for 19.9 percent of the gross domestic product (GDP).1 Employer-sponsored health insurance expenditures of $1,209 billion, Medicare of $719 billion and Medicaid of $587 billion are being increasingly pressured by an inability to further shift costs to employees, a rapidly aging population and low income coverage expansion.

Consolidation by hospitals, health systems, insurers and manufacturers have resulted in higher prices. Specialty and branded drug costs have exploded. Rising out-of-pocket costs have made healthcare unaffordable for low-to-moderate-income Americans, i.e., the two-thirds of the population with household income ................
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